Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Free or low-cost insurance from Medicaid or the Children s Health Insurance Program (CHIP), known as NJ FamilyCare you stay well A new tax credit that can help pay your premiums for health coverage Who can use this application? Use this application to apply for anyone in your family. Apply even if you or your child already has health coverage. You could be eligible for lower-cost or free coverage. If you re single, you may be able to use a short form. Visit njfamilycare.org. Families that include immigrants can apply. You can apply for your immigration status or chances of becoming a permanent resident or citizen. d to complete Appendix C. THINGS TO KNOW Apply faster online What you may need to apply Apply faster online at njfamilycare.org. Social Security Numbers (or document numbers for any legal immigrants who need insurance) Employer and income information for everyone in your family (for example, from paystubs, W-2 forms, or wage and tax statements) Policy numbers for any current health insurance Information about any job-related health insurance available to your family Why do we ask for this information? What happens next? We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We ll keep all the information you provide private and secure, as required by law. To view the Privacy Act Statement, go to njfamilycare.org. Send your complete, signed application to the address on page 7. If you don t have all the information we ask for, sign and submit your application anyway. We ll follow-up with you within 1 2 weeks. You ll get instructions on the next steps to complete your health coverage. If you don t hear from us, visit njfamilycare.org or call 1-800-701-0710. Filling out this application doesn t mean you have to buy health coverage. Get help with this application Online: njfamilycare.org Phone: Call our Help Center at 1-800-701-0710. In person: There may be counselors in your area who can help. Visit our website or call 1-800-701-0710 for more information. En Español: Llame a nuestro centro de ayuda gratis al 1-800-701-0710. NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720).

STEP 1 Tell us about yourself. (We need one adult in the family to be the contact person for your application.) 1. First name, Middle name, Last name, & Suffix 2. Home address (Leave blank if you don t have one.) 3. Apartment or suite number 4. City 5. State 6. ZIP code 7. County 8. Current mailing address (if different from home address) 9. Apartment or suite number 10. City 11. State 12. ZIP code 13. County 14. Phone number 15. Other phone number 16. Do you want to get information about this application by email? Yes No Email address: 17. What is your preferred spoken or written language (if not English)? STEP 2 Tell us about your family. Who do you need to include on this application? DO Include: Yourself Your spouse Your children under 21 who live with you Your unmarried partner who needs health coverage Anyone you include on your tax return, even if they don t live with you Anyone else under 21 who you take care of and lives with you You DON T have to include: Your unmarried partner who doesn t need health coverage Your unmarried partner s children (if you re over 21) The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure everyone gets the best coverage they can. Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than 2 people in your family, you ll need to make a copy of the pages and attach them. You don t need to provide immigration status or a Social Security Number (SSN) for family members who don t need health coverage. We ll keep all the information you provide private and secure as required by law. We ll use personal information only to check if you re eligible for health coverage. NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720). Page 1 of 7

STEP 2: PERSON 1 (Start with yourself) Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you with you. 1. First name, Middle name, Last name, & Suffix 2. Relationship to you? SELF 3. Date of birth (mm/dd/yyyy) 4. Sex Male Female 5. Social Security number (SSN) - - We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who s eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778. 6. Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don t file a federal income tax return.) YES. If yes, please answer questions a c. NO. If no, skip to question c. a. Yes No If yes, name of spouse: b. Will you claim any dependents on your tax return? Yes No If yes, list name(s) of dependents: c. Will you be claimed as a dependent on someone s tax return? Yes No If yes, 7. Are you pregnant? Yes No a. If yes, how many babies are expected during this pregnancy? Due Date 8. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.) YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 3. Leave the rest of this page blank. 9. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? Yes No 10. Are you a U.S. citizen or U.S. national? Yes No 11. If you aren t a U.S. citizen or U.S. national, do you have eligible immigration status? Yes. Fill in your document type and ID number below. a. Immigration document type b. Document ID number c. Have you lived in the U.S. since 1996? Yes No d. Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military? Yes No 12. Do you want help paying for medical bills from the last 3 months? Yes No 13. Do you live with at least one child under the age of 19, and are you the main person taking care of this child? Yes No 14. Are you a full-time student? Yes No 15. Were you in foster care at age 18 or older? Yes No 16. If Hispanic/Latino, ethnicity (OPTIONAL check all that apply.) Mexican Mexican American Chicano/a Puerto Rican Cuban Other 17. Race (OPTIONAL check all that apply.) White Black or African American Native American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720). Page 2 of 7

STEP 2: PERSON 1 (Continue with yourself) Current Job & Income Information Employed If you re currently employed, tell us about your income. Start with question 18.. Not employed Skip to question 28. Self-employed Skip to question 27. CURRENT JOB 1: 18. Employer name and address 19. Employer phone number 20. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly 21. Average hours worked each WEEK CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 22. Employer name and address 23. Employer phone number 24. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly 25. Average hours worked each WEEK 26. In the past year, did you: Change jobs Stop working Start working fewer hours None of these 27. If self-employed, answer the following questions: a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? 28. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don t need to tell us about child support, veteran s payment, or Supplemental Security Income (SSI). None Unemployment How often? Pensions How often? Social Security How often? Retirement accounts How often? Alimony received How often? Net farming/fishing How often? Net rental/royalty How often? Other income How often? Type: 29. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You shouldn t include a cost that you already considered in your answer to net self-employment (question 27b). Alimony paid How often? Other deductions How often? Student loan interest How often? Type: 30. YEARLY INCOME: Complete only if your income changes from month to month. If you don t expect changes to your monthly income, skip to the next person. Your total income this year Your total income next THANKS! This is all we need to know about you. NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720). Page 3 of 7

STEP 2: PERSON 2 If you have more than two people to include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete. Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax return if you with you. 1. First name, Middle name, Last name, & Suffix 2. Relationship to you? 3. Date of birth (mm/dd/yyyy) 4. Sex Male Female 5. Social Security number (SSN) - - We need this if you want health coverage and have an SSN. 6. Does PERSON 2 live at the same address as you? Yes No If no, list address: 7. Does PERSON 2 plan to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don t file a federal income tax return.) YES. If yes, please answer questions a c. NO. If no, skip to question c. a. Yes No If yes, name of spouse: b. Will PERSON 2 claim any dependents on his or her tax return? Yes No If yes, list name(s) of dependents: c. Will PERSON 2 be claimed as a dependent on someone s tax return? Yes No If yes, 8. Is PERSON 2 pregnant? Yes No a. If yes, how many babies are expected during this pregnancy? Due Date 9. Does PERSON 2 need health coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.) YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 5. Leave the rest of this page blank. 10. Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? Yes No 11. Is PERSON 2 a U.S. citizen or U.S. national? Yes No 12. If PERSON 2 isn t a U.S. citizen or U.S. national, do they have eligible immigration status? Yes. Fill in their document type and ID number below. a. Document type b. Document ID number c. Has PERSON 2 lived in the U.S. since 1996? Yes No d. Is PERSON 2, or their spouse or parent a veteran or an activeduty member in the U.S. military? Yes No 13. Does PERSON 2 want help paying for medical bills from the last 3 months? Yes No 14. Does PERSON 2 live with at least one child under the age of 19, and are they the main person taking care of this child? Yes No 15. Was PERSON 2 in foster care at age 18 or older? Yes No Please answer the following questions if PERSON 2 is 22 or younger: 16. Did PERSON 2 have insurance through a job and lose it within the past 3 months? Yes No a. If yes, end date: b. Reason the insurance ended: 17. Is PERSON 2 a full-time student? Yes No 18. If Hispanic/Latino, ethnicity (OPTIONAL check all that apply.) Mexican Mexican American Chicano/a Puerto Rican Cuban Other 19. Race (OPTIONAL check all that apply.) White Black or African American Native American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Now, tell us about any income from PERSON 2 NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720). Page 4 of 7

STEP 2: PERSON 2 Current Job & Income Information Employed If you re currently employed, tell us about your income. Start with question 20.. Not employed Skip to question 30. Self-employed Skip to question 29. CURRENT JOB 1: 20. Employer name and address 21. Employer phone number 22. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly 23. Average hours worked each WEEK CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.) 24. Employer name and address 25. Employer phone number 26. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly 27. Average hours worked each WEEK 28. In the past year, did PERSON 2: Change jobs Stop working Start working fewer hours None of these 29. If self-employed, answer the following questions: a. Type of work b. How much net income (profits once business expenses are paid) will you get from this self-employment this month? 30. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don t need to tell us about child support, veteran s payment, or Supplemental Security Income (SSI). None Unemployment How often? Pensions How often? Social Security How often? Retirement accounts How often? Alimony received How often? Net farming/fishing How often? Net rental/royalty How often? Other income How often? Type: 31. DEDUCTIONS: Check all that apply, and give the amount and how often you get it. If PERSON 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You shouldn t include a cost that you already considered in your answer to net self-employment (question 29b). Alimony paid How often? Other deductions How often? Student loan interest How often? Type: 32. YEARLY INCOME: Complete only if PERSON 2 s income changes from month to month. If you don t expect changes to PERSON 2 s monthly income, add another person or skip to the next section. PERSON 2 s total income this year PERSON 2 s total income next year THANKS! This is all we need to know about PERSON 2. NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720). Page 5 of 7

STEP 3 Native American Indian or Alaska Native (AI/AN) family member(s) 1. Are you or is anyone in your family Native American Indian or Alaska Native? If No, skip to Step 4. Yes. If yes, go to Appendix B. STEP 4 Your Family s Health Coverage Answer these questions for anyone who needs health coverage. 1. Is anyone enrolled in health coverage now from the following? YES. If yes, check the type of coverage and write the person(s) name(s) next to the coverage they have. NO. Medicaid NJ FamilyCare Medicare TRICARE (Don t check if you have direct care or Line of Duty) VA health care programs Peace Corps Employer insurance Name of health insurance: Policy number: Is this COBRA coverage? Yes No Is this a retiree health plan? Yes No Other Name of health insurance: Policy number: Yes No 2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else s job, such as a parent or spouse. YES. If yes, you ll need to have your employer complete Appendix A and return to address provided. NO. If no, continue to Step 5. STEP 5 Select your Health Plan Choose a Health Plan from the list below. If you do not choose now, you will have an opportunity to select a Health Plan before enrollment TTY 1-800-701-0720. Aetna Better Health of New Jersey (Available in ALL counties) Amerigroup New Jersey, Inc. (Available in ALL counties; except Salem county) Horizon NJ Health (Available in ALL counties) UnitedHealthcare Community Plan (Available in ALL counties) WellCare Health Plans of New Jersey (Available in ALL counties, except Burlington, Cape May, Hunterdon and Ocean counties) I understand that if I m found eligible and because I have joined a Health Plan, I must follow the rules for obtaining health care from the Health Plan. I understand that I must let my Health Plan and NJ FamilyCare know if there is any change in the number of people in my family and that any newborn children will be enrolled in my Health Plan. I understand that, unless I, or a family member, have a true medical emergency, I must call my personal doctor for medical advice, medical care or for a referral to a specialist. I understand that if I, or a family member, have a true medical emergency, I must call my personal doctor or the Health Plan as soon as possible after I, or the family member, go to the hospital. I understand that I must keep any medical appointment I have scheduled with a doctor and, if I cannot, I must call the doctor s office to cancel the appointment. I understand that if I go to a doctor other than my personal doctor I have selected, without a referral from my doctor or approval from the Health Plan, I may have to pay for that doctor s services because NJ FamilyCare will not pay for the unapproved service or visit. I understand that I may change to another Health Plan and that I can call the Health Benefits Coordinator to help me do that. I give permission for the release of my medical history and health care records and those of my family members who will be enrolled to any person(s) in the Health Plan and its providers who shall provide or coordinate health care to me and my family as long as I am a member of the Health Plan. NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720). Page 6 of 7

STEP 6 Read & sign this application. I understand that the NJ FamilyCare program may use or disclose protected health information about me or my children if Federal privacy law requires or allows it, or if State law requires it. I understand that the outcome of this application may be shared with any Provider providing services or who provided I understand that I must tell NJ FamilyCare immediately about any changes in my information, such as a change in income, address, family size, if someone in my household is expecting a baby, or if anyone in my household who applied for member(s) of my household. I know that I must call 1-800-701-0710 (TTY 1-800-701-0720) to report any changes. I authorize the NJ Division of Taxation to release my tax return information to NJ FamilyCare. I also authorize any educational institution or school district to release my medical records or those of my child(ren) to the NJ FamilyCare program for the purpose of determining eligibility and billing the Program. We need this information to check your eligibility for help paying for health coverage if you choose to apply. We ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, NJ Division of Taxation, and/or a consumer reporting agency. If the information doesn t match, we may ask you to send us proof. Renewal of coverage in future years To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow NJ FamilyCare to use income data, including information from tax returns. NJ FamilyCare will send me a notice, let me make any changes, and I can opt out at any time. If anyone on this application is eligible for NJ FamilyCare I am giving to the NJ FamilyCare agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I am also giving to the NJ FamilyCare agency rights to pursue and get medical support from a spouse or parent. Does any child on this application have a parent living outside of the home? Yes No If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell NJ FamilyCare and I may not have to cooperate. My right to appeal If I think NJ FamilyCare has made a mistake, I can appeal its decision. To appeal means to tell someone at NJ FamilyCare that I NJ FamilyCare at 1-800-701-0710. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me. Estate Recovery I understand that Medicaid payments for services received on or after age 55 may be reimbursable to the State of New Jersey be limited to, capitation payments made to a managed care organization (MCO) or transportation broker for health coverage, transportation broker. For more information about Estate Recovery, visit http://www.state.nj.us/humanservices/dmahs/ clients/the_nj_medicaid_program_and_estate_recovery_what_you_should_know.pdf Sign this application. may sign here, as long as you have provided the information required in Appendix C. Signature Date (mm/dd/yyyy) NOTE: The submission of a Social Security number (SSN) is mandatory in accordance with 42 U.S.C. 1320b-7. The SSNs provided (including for a husband or wife, family members, or dependents) will be used to associate records pertaining to applicants and other to the extent it is useful in verifying eligibility or the amount of medical assistance payments under 42 CFR 435.940 through 435.960, and preventing duplicate audits. These procedures are designed to determine eligibility and to identify persons who fraudulently or wrongfully participate in Medicaid and DMAHS STEP 7 Mail Completed Application. Mail your signed application to: NJ FamilyCare PO BOX 8367 TRENTON, NJ 08650-9802 NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720). Page 7 of 7

APPENDIX A Health Coverage from Jobs You DON T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage. Tell us about the job that offers coverage. You need to include this page when you send in your application. EMPLOYEE Information 1. Employee name (First, Middle, Last) 2. Employee Social Security number EMPLOYER Information - - 3. Employer name 4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code - 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address 13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? Yes (Continue) 13a. If you re in a waiting or probationary period, when can you enroll in coverage? List the names of anyone else who is eligible for coverage from this job. (mm/dd/yyyy) Name: Name: Name: No (Stop here and go to Step 5 in the application) Tell us about the health plan offered by this employer. 14. Does the employer offer a health plan that meets the minimum value standard*? Yes No 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly 16. What change will the employer make for the new plan year (if known)? Employer won t offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly Date of change (mm/dd/yyyy): *An employer-sponsored health plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Español, llame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We ll get you help at no cost to you. TTY users should call 1-800-701-0720.

APPENDIX B Native American Indian or Alaska Native Family Member (AI/AN) Complete this appendix if you or a family member are Native American Indian or Alaska Native. Submit this with your NJ FamilyCare Application for Health Coverage & Help Paying Costs. Tell us about your Native American Indian or Alaska Native family member(s). Native American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. NOTE: If you have more people to include, make a copy of this page and attach. 1. Name (First name, Middle name, Last name) AI/AN PERSON 1 AI/AN PERSON 2 First Middle First Middle Last Last 2. Member of a federally recognized tribe? Yes Yes If yes, tribe name If yes, tribe name No No 3. Has this person ever gotten a service from Yes Yes the Indian Health Service, a tribal health program, or urban Indian health program, No No or through a referral from one of these If no, is this person eligible to get If no, is this person eligible to get programs? services from the Indian Health services from the Indian Health Service, tribal health programs, or Service, tribal health programs, or urban Indian health programs, or urban Indian health programs, or through a referral from one of these through a referral from one of these programs? programs? Yes No Yes No 4. Certain money received may not be counted for NJ FamilyCare. List any income (amount and how often) reported on your application that includes money from these sources: Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations) Money from selling things that have cultural significance How often? How often? NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Español, llame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We ll get you help at no cost to you. TTY users should call 1-800-701-0720.

APPENDIX C Assistance with Completing this Application You can choose an authorized representative. You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an authorized representative. If you ever need to change your authorized representative, contact NJ FamilyCare. If you re a legally appointed representative for someone on this application, submit proof with the application. 1. Name of authorized representative (First name, Middle name, Last name) 2. Address 3. Apartment or suite number 4. City 5. State 6. ZIP code 7. Phone number 8. Organization name 9. ID number (if applicable) By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this agency. 10. Your signature 11. Date (mm/dd/yyyy) For certified application counselors, navigators, agents, and brokers only. Complete this section if you re a certified application counselor, navigator, agent, or broker filling out this application for somebody else. 1. Application start date (mm/dd/yyyy) 2. First name, Middle name, Last name, & Suffix 3. Organization name 4. ID number (if applicable) NEED HELP WITH YOUR APPLICATION? Visit njfamilycare.org or call us at 1-800-701-0710. Para obtener una copia de este formulario en Español, llame 1-800-701-0710. If you need help in a language other than English, call 1-800-701-0710 and tell the customer service representative the language you need. We ll get you help at no cost to you. TTY users should call 1-800-701-0720.

Discrimination is Against the Law NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, age or disability. NJ FamilyCare does not exclude people or treat them differently because of race, color, national origin, sex, age or disability. NJ FamilyCare: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, please contact 1-800-701-0710 (TTY: 1-800-701-0720). If you believe that NJ FamilyCare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, sex, age or disability, you can file a grievance with the NJ FamilyCare Civil Rights Coordinator via the following: NJ Civil Rights Coordinator, NJ Department of Human Services, Office of Legal and Regulatory Affairs, P.O. Box 700, Trenton, NJ 08625-0700, 609-777-2026, DHS-CO.OLRA@dhs.state.nj.us. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also electronically file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services SW, Room 509F, HHH Building 200 Independence Avenue Washington, D.C. 20201 1-800-368-1019, 1-800-537-7697 (TDD) U.S. Department of Health and Human Services complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. STATE OF NEW JERSEY Department of Human Services Division of Medical Assistance and Health Services Non-Discrimination Statement If you speak any other language, language assistance services are available at no cost to you. Call 1-800-701-0710 (TTY: 1-800-701-0720). NJFC-NDS-0417

New Jersey Non-Discrimination Statement. :.

1 2 3 4 5 6 New Jersey Voter Registration Application Please print clearly in ink. All information is required unless marked optional. Check boxes o New Registration o Address Change o Political Party Affiliation that apply: o Name Change o Signature Update or Non-affiliation Change Are you a U.S. Citizen? o Yes o No Are you at least 17 years of age? o Yes o No (If No, DO NOT complete this form) (If No, DO NOT complete this form) Last Name First Name Middle Name or Initial Suffix (Jr., Sr., III) Date of Birth NJ Driver s License Number or MVC Non-driver ID Number If you DO NOT have a NJ Driver s License or MVC Non-Driver ID, provide the last 4 digits of your Social Security Number. o I swear or affirm that I DO NOT have a NJ Driver s License, MVC Non-driver ID or a Social Security Number. Home Address (DO NOT use PO Box) Apt. Municipality County State Zip Code FOR OFFICIAL USE ONLY Clerk Registration # 33 Office Time Stamp 7 Mailing Address if different from above Apt. Municipality County State Zip Code 8 9 Last Address Registered to Vote (DO NOT use PO Box) Former Name if Making Name Change Apt. Municipality County State Zip Code a. Day Phone Number (Optional) o by mail o in person b. E-Mail Address (Optional) 10 Do you wish to declare a political party affiliation? o Yes, the party name is. (Optional) o No, I do not wish to be affiliated with any political party. 11 Gender o Female o Male Declaration - I swear or affirm that: I am a U.S. Citizen I live at the above address I am at least 17 years old, and understand that I may not vote until reaching the age of 18. I will have resided in the State and county at least 30 days before the next election I am not on parole, probation or serving a sentence due to a conviction for an indictable offense under any federal or state laws I understand that any false or fraudulent registration may subject me to a fine of up to 15,000, imprisonment up to 5 years, or both pursuant to R.S. 19:34-1 Signature: Sign or mark and date on lines below X Date If applicant is unable to complete this form, print the name and address of individual who completed this form. Name Date Address Important Instructions for sections 5, 6 and 10 5) Registrants who are submitting this form by mail and are registering to vote for the first time: If you do not have any of the information required by section 5, or the information you provide cannot be verified, you will be asked to provide a COPY of a current and valid photo ID, or a document with your name and current address on it to avoid having to provide identification at the polling place. Note: ID Numbers are Confidential and will not be released by any governmental agency. Any person who uses such numbers illegally shall be subject to criminal penalties. 6) If you are homeless, you may complete section 6 by providing a contact point or the location where you spend most of your time. 10) You may declare a political party affiliation or you may declare to be unaffiliated, regardless of any prior party affiliation. If you are a previously affiliated voter who wants to change political party affiliation or become unaffiliated, you must file this form no later than 55 days before the primary election in order to vote in the primary election. Completing section 10 is OPTIONAL and will not affect the acceptance of your voter registration application. Need More Information? Check boxes below if you would like to receive more information about: o voting by mail o polling place accessibility o available election materials in o becoming a poll worker o voting if you have a disability, this alternative language: including visual impairment For further information visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837) NJ Division of Elections - 02/16/16

FOLD FOLD n You will be 18 years of age by the next election n You will be a resident of the county 30 days before the election n You are NOT currently serving a sentence, probation orparole because of a felony conviction If it is not accepted, you will be notified on how to complete and/or correct the application. FOLD 1 New Jersey Voter Registration Information You can register to vote if: You are a United States citizen. You are at least 17 years of age.* You will be a resident of the State and county 30 days before the election. You are NOT currently serving a sentence, probation or parole because of a felony conviction. *You may register to vote if you are at least 17 years old but cannot vote until reaching the age of 18. Registration Deadline: 21 days before an election Your County Commissioner of Registration will notify you if your application is accepted. If it is not accepted, you will be notified on how to complete and/or correct the application. Questions? visit Elections.NJ.gov or call toll-free 1-877-NJVOTER (1-877-658-6837) FOLD 2 FOLD Important: Print out at 100% - DO NOT REDUCE. Fold as illustrated to ensure proper mailing. New Jersey Voter Registration You can register to vote if: n You are a United States citizen Registration Deadline: 21 days before an election Your County Commissioner of Registration will notify you if your application is accepted. Put both pages together as shown 1 fold top down 3 TAPE HERE NJ DIVISION OF ELECTIONS PO BOX 304 TRENTON NJ 08625-9983 2 fold bottom up 3 Tape top shut